Download Renal Salvage in a Patient With a Solitary Kidney

CHALLENGING CASES
Renal Salvage in a
Patient With a
Solitary Kidney
A challenging renal artery stent placement procedure.
BY EDWARD MINER, MD, AND ZVONIMIR KRAJCER, MD
CA SE REPORT
A 59-year-old woman was transferred to our institution for severe renal failure and uncontrolled arterial
hypertension. Six weeks before being referred to our service, she had undergone right renal artery stenting for
fibromuscular dysplasia at an outside facility. Her medical
history was also pertinent for left renal cell carcinoma.
The interventional procedure was performed 1 day prior
to the left renal nephrectomy. Aspirin or clopidogrel was
not administered after the renal artery intervention due
to the pending left nephrectomy.
After surgery, the patient developed
severe renal failure, with a serum creatinine level reaching 4.1 mg/dL. Angiography performed at the outside facility
revealed complete occlusion of the right
renal artery stent with patent flow through
a small lower pole accessory renal artery
(Figure 1). An attempt to open the main
right renal artery at the outside facility was
unsuccessful.
The patient was transferred to our
care, and a second attempt was made to
open the occluded renal stent 30 days
after the initial intervention. A renal
ultrasound revealed preserved right renal
size of 10.5 cm X 5 cm, indicating likely
renal viability.
END OVA SCUL AR PRO CEDURE
Because of advanced renal failure, oral
N-acetylcysteine and intravenous sodium
bicarbonate were administered before and
for 24 hours after the procedure. Gadolinium was used as the contrast agent.
A 7-F, 11-cm sheath (Cordis Corporation, a Johnson &
Johnson company, Warren, NJ) was placed in the left
femoral artery. A 7-F, Renal Double Curve guide
catheter (Boston Scientific Corporation, Natick, MA)
was advanced to the right renal artery under fluoroscopic guidance, and angiography was performed. The
lesion was crossed with a .014-inch PT-Graphix wire
(Boston Scientific Corporation) (Figure 2). A Guidant
Voyager 2-mm X 8-mm balloon (Abbott Vascular, Santa
Clara, CA) was advanced to the lesion, and multiple
inflations to 15 atm were performed.
Figure 1. Renal angiography showing complete occlusion of the right main
renal artery that was previously stented.
NOVEMBER 2007 I ENDOVASCULAR TODAY I 35
CHALLENGING CASES
The patient did well after the procedure and had normalization of her renal function. Her arterial hypertension was well controlled on 5 mg of amlodipine. Her
serum creatinine level at 2 years follow-up remained stable at 1.4 mg/dL. The renal duplex evaluation at 2-year
follow-up revealed no evidence of recurrent stenosis
(Figure 4).
This balloon was exchanged for a 3.75-mm X 10-mm
Cutting Balloon (Boston Scientific Corporation), and
multiple inflations to 10 atm were performed. This balloon was exchanged for a 4-mm X 20-mm PolarCath balloon (Boston Scientific Corporation), which was inflated
to 8 atm at -10º C for three inflations.
The cryoplasty balloon was then exchanged for
Multi-Link Vision 4-mm X 23-mm and 4-mm X 8-mm
coronary stents (Abbott Vascular), which were each
deployed at 17 atm for 15 seconds. Final angiography
showed a patent renal artery with minimal residual
stenosis (Figure 3).
DISCUSSI ON
Renal artery stenting is a well-recognized and reliable
treatment for hemodynamically significant renal artery
stenosis.1-3 The indications for renal artery stenting
include patients with poorly controlled hypertension on
multiple medications (three or more, or those who are
intolerant of antihypertensive medications) patients
with ischemic nephropathy (for preservation of renal
function, when experiencing deteriorating renal size
and/or function); and patients with a known history of
coronary ischemia, heart failure, angina, or flash pulmonary edema, which is worsened by renovascular
hypertension.
In the setting of fibromuscular dyplasia, angioplasty
alone is generally the preferred approach, with excellent
procedural and clinical results.4 Renal artery stenting is usually reserved for bailout in cases of dissection or suboptimal
results from angioplasty.4 In this case, the indication for primary stenting in the initial renal artery intervention performed at an outside institution was not clear. By contrast,
for ostial, atherosclerotic renal artery stenosis, stenting as an
initial strategy has been shown to be superior to angioplasty alone.5
Renal salvage for acute occlusion of a renal artery is a
less common but also important indication for renal
Figure 3. Final angiography after the interventional procedure showing a patent right renal artery.
Figure 4. Two-year follow-up duplex renal study showing normal renal artery velocities and normal renal:aortic velocity ratio.
Figure 2. Hydrophilic .014-inch PT Graphix guidewire
(Boston Scientific Corporation) across total in-stent renal
artery occlusion.
36 I ENDOVASCULAR TODAY I NOVEMBER 2007
CHALLENGING CASES
artery stenting, as is illustrated in this case.6 Renal “hibernation” should be considered in recently occluded renal
arteries with preserved renal size. It should also be considered in patients with risk factors and overt evidence
of atherosclerosis who experience acute renal failure.6 A
recent case series by Dwyer and coauthors demonstrated the efficacy of percutaneous renal revascularization in
achieving renal salvage and preventing permanent need
for hemodialysis in five patients with acute renal failure.6
Renal duplex is a useful technique for screening patients
with suspected renovascular hypertension and for evaluating of recurrent renal artery stenosis after renal artery intervention.7,8
Recanalizing total occlusions of the renal arteries
demands knowledge of available coronary artery technology and techniques. Cutting balloons and cryoplasty are
useful in our experience in recanalizing total occlusions
and/or restenosed renal arteries. Although renal stent
thrombosis is rare,5,6 the use of antiplatelet agents in renal
artery stenting is mandatory to decrease the incidence of
acute, thrombotic occlusion of the stented artery. If aspirin
and clopidogrel cannot be administered due to concomitant medical conditions or surgeries, angioplasty alone may
be the preferred approach to prevent acute renal artery
thrombosis. ■
Edward Miner, MD is a Cardiology Fellow at Texas Heart
Institute, St. Luke’s Episcopal Hospital, in Houston, Texas. He
has disclosed that he holds no financial interest in any product or manufacturer mentioned herein. Dr. Miner may be
reached at (832) 355-1000; [email protected].
Zvonimir Krajcer, MD, is Codirector of Peripheral Vascular
Disease Service, Texas Heart Institute, St. Luke's Episcopal
Hospital, in Houston, Texas. He has disclosed that he receives
research funding from Boston Scientific and is a paid consultant to Gore, Boston Scientific, and Abbott. Dr. Krajcer
may be reached at (713) 790-9401; [email protected].
1. Rocha-Singh KJ, Ahuja RK, Sung CH, et al. Long-term renal function preservation after
renal artery stenting in patients with progressive ischemic nephropathy. Catheter Cardiovasc
Interv. 2002;57:135-141.
2. Ramos F, Kotliar C, Alvarez D, et al. Renal function and outcome of PTRA and stenting for
atherosclerotic renal artery stenosis. Kidney Int. 2003;63:276-282.
3. Mackrell PJ, Langan EM III, Sullivan TM, et al. Management of renal artery stenosis:
effects of a shift from surgical to percutaneous therapy on indications and outcomes. Ann
Vasc Surg. 2003;17:54-59.
4. Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med. 2004;350:1862-1871.
5. Van de Ven PJ, Kaatee R, Beutler JJ, et al. Arterial stenting and balloon angioplasty in
ostial atherosclerotic renovascular disease: a randomized trial. Lancet 1999;23:282-286.
6. Dwyer KM, Vrazas JL, Lodge, RS, et al. Treatment of acute renal failure caused by renal
artery occlusion with renal artery angioplasty. Am J Kidney Dis. 2002;40:189-184.
7. Radermacher J, Chavan A, Bleck J, et al. Use of Doppler ultrasonography to predict the
outcome of therapy for renal artery stenosis. N Engl J Med. 2001;344:410-417.
8. Girndt M, Kaul H, Maute C, et al. Enhanced flow velocity after stenting of renal arteries is
associated with decreased renal function. Nephron Clin Pract. 2007;105:c84-c89.